HomeMy WebLinkAbout615 S LOOMIS AVE - APPLICATIONS - 2/6/2013City of
�.Fort Collins
Planning, Development & Transportation
281 N. College Ave P.O. Box 580
Fort Collins, CO 80524
Phone 970-416-2740 Fax 224-6134
OVER-THE-COUNTER PERMITS ONLY
This application is to be used to apply for the following permits only (check all that apply). ❑ Air Conditioning
❑ Demolition (interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
❑ Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation ❑ Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicable information
�on/the application. Incomplete applications will not be accepted.
Application #_ �) �U�`� i`1 Date
For office use only
Job Site Address (required)
Value of Constr ction (labor, materials, profit)
1Is
PCope ner Name Address
cd
City/State Zip
�LOA-CO
PhonP.t.,
tnn I-�5 S
Applicant Name Address
FEB IN 2,013 U 91&kCezkA
ty/State Zip
LF54621A lq-70-55
Phone
Contractor Address
IFOA f� 70S C0MW ce.
City/State Zip
F FL D
Phone
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
El Flere 0 Report
sales raxnu berlsreQuiredbyaumnaacrors
Are you paying with your trust account?
❑ Yes ❑ No
Is this a residential or commercial project? Residential El Commercial
If residential, is it: ❑ Single Family Detached ❑ Condo/townhome (single family attached) Duplex
0 Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church 0 Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? ❑ Yes X% Ifyes, you may need to cOnMCt Historic PreserVat/on
If this is for a demolition permit, what year was the building constructed?
If prior to 1975,' you will need an asbestos assessment to submit with this application.
Description of work
*If lawn sprinkler/backilow preventer, must list licensed plumber. If flrst-time A/C, must list licensed electrician.
Subcontractors: List the company name or Gty of Ft Collins license #
Electrician Plumber Mechanical Roofer Other
I hereby acknowledge that I have read this application and state -that the above information is complete and correct. I agree to
comply with all requirements contained herein and city ordinances and state laws regulating building construction. I know that a
permit is not valid until It has been paid and issued.
Applicant: Print
ri
PrintName:4.P,1
Date ' V 3
53